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In her report on Quebec's handling of long-term care home deaths during the pandemic, coroner Géhane Kamel recommended that the government applies the precautionary principle every time it evaluates risks.Ryan Remiorz/The Canadian Press

The mass deaths in Quebec nursing homes during the first wave of COVID-19 stemmed not just from a lack of resources and personnel but also from officials who had tunnel vision and failed to apply the basic precautionary principle, a coroner says in her report about the province’s handling of the crisis.

In a report released Monday, coroner Géhane Kamel questioned the independence of Horacio Arruda, who was Quebec’s director of public health but also a health assistant-deputy minister.

Ms. Kamel’s inquest was the only official Canadian probe to hold public hearings into what happened in the spring of 2020. She looked at 53 deaths in six facilities, among the more than 4,800 elderly Quebeckers who died in congregate living settings during the pandemic’s first wave.

The coroner noted that Dr. Arruda testified that he had to balance his opinion on whether to wear masks with the availability of protective gear. “Would his advice be the same if he didn’t have to worry about being out of stock? I think not. … This is the danger of wearing two hats.”

Coroners’ recommendations are not binding. Nevertheless, the report was hailed by unions, who had been unhappy about their members having to work without adequate protection, such as N-95 respirators. “We had been shouting loud and clear but were not heard,” Isabelle Groulx, vice-president of the FIQ nursing union, said in an interview. “The government cannot turn a deaf ear to this report.”

Patrick Martin-Ménard, a lawyer representing families of deceased nursing-home residents, lauded the coroner for recommending that local health administrators should be held more accountable for the care dispensed to seniors. “The officials who were in charge at the time, who are responsible for this carnage, are still in charge,” he said in an interview.

Two key government decisions weren’t based on scientific evidence, the report said.

The first was the focus on helping hospitals rather than nursing homes. “[Dr. Arruda] claimed that nursing homes were less likely to be hit by COVID-19 than hospitals. From that opinion, which wasn’t based on any solid evidence, they justified the decision to prioritize resources to acute care settings and not to increase preventive measures … in long-term care.”

The other decision was barring family caregivers from visiting nursing homes. It was intended to prevent infections and protect relatives, who also tend to be older. “That information is not supported and is almost infantilizing toward families,” Ms. Kamel said.

Family caregivers were a crucial help to short-staffed nursing homes. “There is no doubt in my mind that the presence of family caregivers would have given some elders a chance of survival.”

Ms. Kamel recommended that the government applies the precautionary principle every time it evaluates risks. Following that principle means applying maximum precautions until a better grasp of the problem allows safeguards to be eased off.

The opposite happened during the first wave: Officials initially limited the use of masks and refused to consider the possibility of asymptomatic transmission.

But the seeds of the disaster had been planted years earlier, by a repeated failure to finance elder care properly, the report said. “All the elements were there to create this catastrophe.”

A large part of the inquest focused on the troubled Herron nursing home and efforts by the local Montreal health authority, known by the initials CIUSSS ODIM, to intervene after staffers abandoned the facility and left feeble residents lying in their wastes.

The report notes that the privately owned Herron was ineptly managed. But Mr. Martin-Ménard praised the report for also noting that most of the deaths at Herron occurred after the CIUSSS took over in a disorganized way.

Once the ghastly situation at Herron became public, the chief executive officer of the CIUSSS, Lynne McVey, asked police to investigate. Ms. Kamel’s report said the call seemed more intended to blame the Herron owners and minimize the role of the health authority.

The coroner also said it was “egregious” of Ms. McVey to scold the Herron owners for sending ailing residents to hospital.

The report sheds new light into many of the deaths that Ms. Kamel investigated. In 12 of the 53 cases, the deaths were not directly caused by COVID-19 but either could not be determined with certainty, or were linked to the neglect and disarray in nursing homes.

The most troubling case was that of Leon Barrette, who was transferred from hospital to the Herron home just when the COVID-19 outbreak started. “Notes in his file are so vague we’re left with the impression he was forgotten in his room and died alone.”

Ms. Kamel said Mr. Barrette likely died from fluids accumulating in his lungs after he was left unattended in a supine position.

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